1. Tetanus and Tetanus Toxoid Epidemiology and Prevention of Vaccine- Preventable Diseases National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention Revised March 2008

2. Note to presenters: Images of vaccine-preventable diseases are available from the Immunization Action Coalition website at http://www.vaccineinformation.org/photos/index.asp

3. Tetanus First described by Hippocrates Etiology discovered in 1884 by Carle and Rattone Passive immunization used for treatment and prophylaxis during World War I Tetanus toxoid first widely used during World War II

4. Clostridium tetani Anaerobic gram-positive, spore- forming bacteria Spores found in soil, animal feces; may persist for months to years Multiple toxins produced with growth of bacteria Tetanospasmin estimated human lethal dose = 2.5 ng/kg

5. Tetanus Pathogenesis Anaerobic conditions allow germination of spores and production of toxins Toxin binds in central nervous system Interferes with neurotransmitter release to block inhibitor impulses Leads to unopposed muscle contraction and spasm

6. Tetanus Clinical Features Incubation period; 8 days (range, 3-21 days) Three clinical forms: local (not common), cephalic (rare), generalized (most common) Generalized tetanus: descending symptoms of trismus (lockjaw), difficulty swallowing, muscle rigidity, spasms Spasms continue for 3-4 weeks Complete recovery may take months

7. Neonatal Tetanus Generalized tetanus in newborn infant Infant born without protective passive immunity Estimated more than 250,000 deaths worldwide in 2000-2003* *www.who.int/immunization_monitoring/diseases/neonatal_tetanus/en/index.html

8. Tetanus Complications Laryngospasm Fractures Hypertension Nosocomial infections Pulmonary embolism Aspiration pneumonia Death

9. Tetanus Wound Management Vaccination History Unknown or less than 3 doses 3 or more doses Td*TIG YesNo No + No Td*TIGYes No**No Clean, minor wounds All other wounds * Tdap may be substituted for Td if the person has not previously received Tdap and is 10 years or older + Yes, if more than 10 years since last dose ** Yes, if more than 5 years since last dose

10. Tetanus Epidemiology ReservoirSoil and intestine of animals and humans Transmission Contaminated wounds Tissue injury Temporal pattern Peak in summer or wet season CommunicabilityNot contagious

11. Tetanus—United States, 1947-2006 Year

12. Tetanus—United States, 1980-2006 Year

13. Tetanus—United States, 1980-2003 Age Distribution N=1,277

14. Age Distribution of Reported Tetanus Cases, 1991-1995 and 1996-2000

15. Tetanus—1998-2000 Injuries and Conditions Data available for 129 of 130 reported cases. Source: MMWR 2003;52(SS-3):1-12

16. DTaP, DT, and Td DTaP, DT Td, Tdap (adult) Diphtheria 7-8 Lf units 2-2.5 Lf units Tetanus 5-12.5 Lf units 5 Lf units DTaP and pediatric DT used through age 6 years. Adult Td for persons 7 years and older. Tdap for persons 10-18 years (Boostrix) or 11-64 years (Adacel)

17. Tetanus Toxoid Formalin-inactivated tetanus toxin ScheduleThree or four doses + booster Booster every 10 years EfficacyApproximately 100% DurationApproximately 10 years Should be administered with diphtheria toxoid as DTaP, DT, Td, or Tdap

18. Routine DTaP Primary Vaccination Schedule Dose Primary 1 Primary 2 Primary 3 Primary 4 Age 2 months 4 months 6 months 15-18 months Interval --- 4 wks 6 mos

19. Children Who Receive DT The number of doses of DT needed to complete the series depends on the child’s age at the first dose: – if first dose given at <12 months of age, 4 doses are recommended – if first dose given at ≥12 months, 3 doses complete the primary series

20. Routine DTaP Schedule for Children Younger Than 7 years of Age 4-6 years of age, before entering school 11-12 years of age if 5 years since last dose (Tdap) Every 10 years thereafter (Td) Booster Doses

21. Routine Td Schedule for Unvaccinated Persons 7 Years of Age and Older Dose* Primary 1 Primary 2 Primary 3 Interval --- 4 wks 6-12 mos Booster dose every 10 years *ACIP recommends that one of these doses (preferably the first) be administered as Tdap

22. Diphtheria and Tetanus Toxoids Adverse Reactions Local reactions (erythema, induration) Exaggerated local reactions (Arthus-type) Fever and systemic symptoms not common Severe systemic reactions rare

23. Diphtheria and Tetanus Toxoids Contraindications and Precautions Severe allergic reaction to vaccine component or following a prior dose Moderate or severe acute illness

24. CDC Vaccines and Immunization Contact Information Telephone 800.CDC.INFO Email nipinfo@cdc.gov Website www.cdc.gov/vaccines